Who’s been using PEP—and would they benefit from PrEP?
Since 2005, the Centers for Disease Control has recommended post-exposure prophylaxis (PEP) to prevent HIV infection. PEP, a 28-day course of antiretroviral medications, effectively prevents HIV if it’s started within 72 hours of a potential exposure to HIV from sex or intravenous drug use. But with 50,000 new HIV infections occurring in the U.S. every year, it’s clear that PEP isn’t being used as often as it could be. Using data collected at a large community health center over the past 15 years, two recent studies evaluated who has been accessing and using PEP—and provide insight into how researchers and practitioners can more effectively deploy biomedical prevention strategies moving forward.
“Conversations about who’s using PEP were reignited by new campaigns about PrEP [pre-exposure prophylaxis],” explains Sachin Jain, MD, MPH, lead author of the studies and Infectious Diseases physician at Montefiore Medical Center and Albert Einstein College of Medicine. He says that he and his colleagues were motivated to understand who’s been accessing PEP, what their risk behaviors were, if they completed their PEP regimens, and if they ended up acquiring HIV to better understand who might make good candidates for PrEP.
They evaluated data of patients who were prescribed PEP between 1997 and 2013 at Fenway Health, a large, urban community health center in Boston Massachusetts. Of the 894 total patients who received PEP, most (88%) were men who have sex with men (MSM). The most common reported reason for accessing PEP was consensual condomless sex (61%). Thirty-one percent reported that the condom failed or was removed—the second most common reason cited. Oftentimes (in 62% of cases), the PEP recipient reported not knowing the HIV status of their partner. They saw an increase in the proportion of reported condomless exposures by year.
The researchers then did a second analysis of the 788 MSM who had accessed PEP.
A total of 39 seroconversions happened among these men—all of which occurred more than 90 days after initially requesting PEP. Most happened more than six months after they received PEP, which led the researchers to conclude that the HIV infections that occurred were likely the result of another exposure to HIV—not because the PEP regimen failed.
“The timing speaks to the fact that the HIV infections happened after the [90-day] PEP follow-up period. We suspect that the majority of documented infections were due to recurrent high-risk behavior,” Jain explained.
Interestingly, the researchers did not find an association between HIV infection and repeated PEP use. In other words, men who accessed PEP more than once weren’t any more likely to eventually get HIV than those who only accessed it once. Repeated PEP use is oftentimes used by providers, and is recommended by the CDC, as an indication that an individual should automatically be considered and referred for PrEP.
“I would agree that this is true—that people who use PEP recurrently should be considered for PrEP. However, because our study didn’t observe an association between nPEP recurrence and HIV acquisition, the conversation about PrEP should be started even after PEP is used for the first time. There may be some people that will access PEP just one time, and you may not see them again until they have already become infected with HIV, and it’s too late,” he says.
He encourages providers of PEP to continue to follow up with patients and to spend time on HIV prevention counseling—to assess patients’ risk, over time, to see if they might make good candidates for PrEP once they finish an PEP course.
“It sort of depends, who might be a good candidate for PrEP versus PEP. People with ongoing risk—either with a partner who has HIV or partners of unknown HIV status—these are people that would appear to more obviously benefit from PrEP. An PEP-based approach may be advisable if they’re not anticipating near-term exposures [to HIV] or if they know they will not be sexually active for a certain period of time. Stigma may also factor into a person’s decision to choose episodic PEP over daily PrEP. It comes down to having open and honest conversations with patients about which method(s) fit best with their lifestyles and sexual health goals.”
For basic facts about PrEP and PEP, and additional information about these prevention tools, look here.
Jain, S. and colleagues. Longitudinal trends in HIV nonoccupational postexposure prophylaxis use at a Boston community health center between 1997 and 2013. JAIDS, 68(1), 97-101.
Jain, S. and colleagues. Subsequent HIV infection among men who have sex with men who used non-occupational post-exposure prophylaxis at a Boston community health center: 1997-2013. AIDS Patient Care and STDs, 29(1), 1-6.